Long-Term Hand and Shoulder Function in Children following Early Surgical Intervention for a Birth-Related Upper Brachial Plexus Injury.

Purpose To better understand the long-term hand and shoulder outcomes of upper brachial plexus birth injuries. Methods We evaluated shoulder and hand function in 32 patients (13 males; 19 females) with a C5/C6 birth injury history). All patients had undergone primary nerve surgery as infants, and 12 underwent a simultaneous shoulder procedure as they presented with a fixed internal rotation contracture of the shoulder. On average, all patients were evaluated and examined 15 years postoperatively. The shoulder function was evaluated using the Miami Shoulder Scale. Hand function was measured by the 9-hole peg test (9-HPT) and statistical analysis included comparison of 9-HPT time against normative data using the Student's t -test. Results The cohort includes 22 right-hand-dominant and 10 left-hand-dominant patients. Mean age at surgery was 10 months; mean age at follow-up was 15 years ± 2 years 2 months. Cumulative shoulder function was "good" or "excellent" (Miami score) in 23 patients. For 9-HPT, 23 out of 32 patients seen had an involved hand with a significant alteration in function. Conclusion Early nerve surgery in cases of upper brachial plexus birth injuries result in the desired outcome. To ensure timely and targeted therapy for any residual deficits, it is imperative that limitations in hand function among children with an Erb's palsy.

Long-Term Results of Isolated Latissimus Dorsi to Rotator Cuff Transfer in Brachial Plexus Birth Injury.

Background Brachial plexus birth injury results in deficits in strength and motion, occasionally requiring surgery to restore power to the deficient external rotators of the shoulder in these patients. This is a retrospective analysis of the long-term results of an isolated latissimus dorsi transfer to the rotator cuff in patients with brachial plexus birth injury. Methods This is a retrospective review of prospectively collected data for patients undergoing isolated latissimus dorsi transfer into the infraspinatus in addition to release of the internal rotation contracture of the shoulder with greater than 5 years' follow-up. Preoperative and postoperative shoulder elevation and external rotation were documented. Failure of surgery was defined as a return of the internal rotation contracture and a clinically apparent clarion sign. Results A total of 22 patients satisfied the inclusion criteria: 9 global palsies and 13 upper trunk palsies. The average follow-up was 11 years, ranging from 7.5 to 15.9 years. There was a trend for improved external rotation in the global palsy cohort at final follow-up ( p = 0.084). All nine global palsies maintained adequate external rotation without a clarion sign. Five of the 13 upper trunk palsies failed the latissimus dorsi transfer and subsequently required either teres major transfer and/or rotational osteotomy. In these five failures, the period from initial transfer to failure averaged 6.6 years, ranging from 3.4 to 9.5 years. Conclusion The results of this study indicate that patients with global palsy have sustained long-term improved outcomes with isolated latissimus dorsi transfer while patients with upper trunk palsy have a high rate of failure. Based on these results, we recommend isolated latissimus dorsi transfer for global palsy patients who have isolated infraspinatus weakness. Level of Evidence: Case series - Level IV.

The Use of Botulinum Toxin Injection for Brachial Plexus Birth Injuries: A Systematic Review of the Literature.

BACKGROUND: Most brachial plexus birth injuries (BPBIs) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. METHODS: With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. RESULTS: Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. CONCLUSIONS: The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBIs with a relatively low-risk profile.

Result of modified Outerbridge-Kashiwagi procedure for elbow flexion contractures in brachial plexus birth injury.

We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus birth injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients. Level of evidence: IV.

Complications in Surgery for Brachial Plexus Birth Injury: Avoidance and Treatment.

Brachial plexus birth injuries are rare, with treatment and follow-up often required from infancy until skeletal maturity. We review complications that may occur related to primary nerve surgery or secondary musculoskeletal procedures, and discuss how these may be avoided.

Intravenous Glomus Tumor Masquerading as Lateral Antebrachial Cutaneous Neuroma.

Background: Intravenous glomus tumors are extremely rare. Methods: We report a patient with an intravenous glomus tumor within a venous aneurysm misdiagnosed as a neuroma of the lateral antebrachial cutaneous nerve, based on clinical exam, electrodiagnostic studies, and findings on a magnetic resonance imaging neurogram. Results: After surgical resection, the patient's symptoms, including pain and localized hypersensitivity, totally resolved. Conclusions: This case illustrates 2 important points. First, unlike extradigital glomus tumors, magnetic resonance imaging is not reliable in diagnosing intravenous glomus tumors. Second, in the presence of chronic localized neuroma type pain and sensitivity in the upper limb without a clear cause, an extradigital cutaneous or intravenous glomus tumor must be considered in the differential diagnosis.

Evaluation of Self-Concept and Emotional-Behavioral Functioning of Children with Brachial Plexus Birth Injury.

Background The reported incidence of brachial plexus birth injury (BPBI) is 0.87 to 2.2 per 1,000 live births. The psychological functioning, including self-concept and emotional-behavioral functioning, of children with BPBI has only been examined to a limited extent. Objective The purpose of this study was to describe the self-concept and emotional-behavioral functioning in children with BPBI from both the child's and parent's perspective. Methods Thirty-one children with BPBI, mean age 11 years 1 month, completed the Draw A Person: Screening Procedure for Emotional Disturbance (DAP:SPED) and Piers Harris Children's Self-Concept Scale (PHCSCS). The parents answered questions from the Behavior Assessment System for Children, Parent Rating Scales (BASC-2 PRS). Results The scores from the DAP:SPED drawings showed further evaluation was not strongly indicated in the majority of the children. The PHCSCS Total score demonstrated that the children had a strongly positive self-concept. The parental responses to the BASC-2 PRS indicated that few children were at risk or in the clinically significant range for the four composite scores and all of the component clinical or adaptive scales. Gender comparison revealed females exhibited greater anxiety than males. Conclusion Both children and parents reported a positive psychological well-being for the majority of the children. Parents had greater concerns about their child's social-emotional functioning, particularly anxiety. An interdisciplinary approach (occupational therapy evaluation, clinical observation, and parental interview) is necessary to determine the need for mental health referral.

Lower extremity nerve trauma.

Peripheral nerve injuries of the lower extremity (LE) are frequently encountered in orthopaedic practice. They can be traumatic or iatrogenic. Proper and timely diagnosis and treatment are the keys to optimizing outcomes. This paper reviews and discusses the basic anatomy and physiology of nerve injury and the current literature on the incidence, pathogenesis, diagnosis, management and outcomes of sciatic, femoral, peroneal, and tibial nerve injuries. The purpose of this review is to suggest a protocol for evaluation and management of LE nerve injuries.

Multiple nerve injuries following repair of a distal biceps tendon rupture--case report and review of the literature.

Current repair of a distal biceps tendon rupture has reverted to the single incision technique. Postoperative complications are rare, but the most common are due to neuropraxia. We present the case of patient who sustained multiple nerve injuries following distal biceps repair. This case is presented with a review of the literature.

Practical magnetic resonance imaging evaluation of peripheral nerves in children: magnetic resonance neurography.

Magnetic resonance (MR) imaging is an excellent tool for the evaluation of peripheral nerves in children not only because of its excellent soft tissue contrast resolution but also because it is noninvasive and does not use ionizing radiation. In nonconclusive cases, MR neurography can be complementary to physical examination and electromyography in identifying a specific affected nerve and the site of the lesion. This article reviews the MR imaging technique used in the evaluation of peripheral nerves (ie, MR neurography), its major indications, and the common pathologic conditions encountered in the pediatric population.

Subscapularis slide correction of the shoulder internal rotation contracture after brachial plexus birth injury: technique and outcomes.

Internal rotation contracture is the most common shoulder deformity in patients with brachial plexus birth injury. The purpose of this investigation is to describe the indications, technique, and results of the subscapularis slide procedure. The technique involves the release of the subscapularis muscle origin off the scapula, with preservation of anterior shoulder structures. A standard postoperative protocol is used in all patients and includes a modified shoulder spica with the shoulder held in 60 degrees of external rotation and 30 degrees of abduction, aggressive occupational and physical therapy, and subsequent shoulder manipulation under anesthesia with botulinum toxin injections as needed. Seventy-one patients at 2 institutions treated with subscapularis slide between 1997 and 2010, with minimum follow-up of 39.2 months, were identified. Patients were divided into 5 groups based on the index procedure performed: subscapularis slide alone (group 1); subscapularis slide with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide (group 3); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide combined with tendon transfers for shoulder external rotation (group 4); and subscapularis slide with simultaneous tendon transfers, with no prior brachial plexus surgery (group 5). Full passive external rotation equivalent to the contralateral side was achieved in the operating room in all cases. No cases resulted in anterior instability or internal rotation deficit. Internal rotation contracture of the shoulder after brachial plexus birth injury can be effectively managed with the technique of subscapularis slide.

Hand function in children with an upper brachial plexus birth injury: results of the nine-hole peg test.

AIM: The aim of this study was to evaluate hand function in children with Erb upper brachial plexus palsy. METHOD: Hand function was evaluated in 25 children (eight males; 17 females) with a diagnosed upper (C5/C6) brachial plexus birth injury. Of these children, 22 had undergone primary nerve reconstruction and 13 of the 25 had undergone simultaneous and/or secondary shoulder procedures. Hand function was evaluated using the nine-hole peg test at a mean age of 9 years (SD 2y 2mo), and compared with the contralateral, uninvolved hand. Results were compared with age- and sex-matched population norms, and correlated with shoulder outcomes using the Gilbert and Miami scores. RESULTS: Although shoulder function was graded as good or excellent in 24 of 25 children, hand function as measured by the nine-hole peg test was significantly altered in the involved hand in 80% (p=0.008). On average the participants took 18.8% longer to complete the task with the involved hand; this was significantly different from the expected difference of 7.2% (p=0.008). INTERPRETATION: Hand function is impaired in individuals with upper brachial plexus birth injury. These results suggest that from the initiation of treatment in this population, attention should be paid to recognizing and focusing therapy on subtle limitations of hand function.

Outcome after tendon transfers to restore wrist extension in children with brachial plexus birth injuries.

Children with brachial plexus birth injuries often require tendon transfer to restore active wrist extension and maximize hand function. The purpose of this study is to assess the clinical results in children with brachial plexus birth injuries after tendon transfer to reconstruct active wrist extension. Over a 10-year period, 21 children (11 male, 10 female) underwent tendon transfer to reconstruct active wrist extension by a single surgeon. Eight patients had C5/C6/C7 injury and 13 patients had global palsy (C5-T1). The average age at surgery was 5.5 years (range, 3 to 8 y). Restoration of wrist extension was measured according to the functional scale of Duclos and Gilbert. The mean duration of follow-up was 36 months (minimum follow-up of 1 y). At latest follow-up, 14 (66%) children (C5/C6/C7, n=8; global, n=6) demonstrated active wrist extension ≥ 30 degrees. Within the global injury subcohort, 3 patients demonstrated static extension of the wrist. Four failures occurred in the global palsy group. Children with absent active wrist extension after a brachial plexus birth injury can benefit from a tendon transfer. The more severe global palsy cases have a worse outcome.

Glenohumeral deformity in children with brachial plexus birth injuries.

Shoulder deformity remains the most common musculo-skeletal sequela following a brachial plexus birth injury. The natural history of untreated glenohumeral deformity is one of progression in this unique patient population. In infants and young children with persistent neurological deficits, shoulder dysfunction becomes a major source of morbidity, as these children have extreme difficulty placing the hand in space. The functional limitations due to muscle denervation and the resultant periarticular soft tissue contractures and progressive osseous deformities have been well-characterized. Increasing attention is being given to the glenohumeral dysplasia (GHD) and the associated prevalence of early posterior dislocation of the shoulder in infants with brachial plexus birth injuries. GHD represents a spectrum of findings, including glenoid and humeral head articular incongruities and dysplasia, subluxation, and frank dislocation. This article presents our comprehensive, temporally-based management strategies for the glenohumeral joint deformities in these children utilizing soft tissue and bony reconstructive procedures.

Hypoplasia of the trapezius and history of ipsilateral transient neonatal brachial plexus palsy.

We present two children with hypoplasia of the left trapezius muscle and a history of ipsilateral transient neonatal brachial plexus palsy without documented trapezius weakness. Magnetic resonance imaging in these patients with unilateral left hypoplasia of the trapezius revealed decreased muscles in the left side of the neck and left supraclavicular region on coronal views, decreased muscle mass between the left splenius capitis muscle and the subcutaneous tissue at the level of the neck on axial views, and decreased size of the left paraspinal region on sagittal views. Three possibilities can explain the association of hypoplasia of the trapezius and obstetric brachial plexus palsy: increased vulnerability of the brachial plexus to stretch injury during delivery because of intrauterine trapezius weakness, a casual association of these two conditions, or an erroneous diagnosis of brachial plexus palsy in patients with trapezial weakness. Careful documentation of neck and shoulder movements can distinguish among shoulder weakness because of trapezius hypoplasia, brachial plexus palsy, or brachial plexus palsy with trapezius hypoplasia. Hence, we recommend precise documentation of neck movements in the initial description of patients with suspected neonatal brachial plexus palsy.

Sensory restoration by lateral antebrachial cutaneous to ulnar nerve transfer in children with global brachial plexus injuries.

Selective peripheral nerve transfers represent an emerging reconstructive strategy in the management of both pediatric and adult brachial plexus and peripheral nerve injuries. Transfer of the lateral antebrachial cutaneous nerve of the forearm into the distal ulnar nerve is a useful means to restore sensibility to the ulnar side of the hand when indicated. This technique is particularly valuable in the management of global brachial plexus birth injuries in children for which its application has not been previously reported. Four children ages 4 to 9 years who sustained brachial plexus birth injury with persistent absent sensibility on the unlar aspect of the hand underwent transfer of the lateral antebrachial cutaneous nerve to the distal ulnar nerve. In three patients, a direct transfer with a distal end-to-side repair through a deep longitudinal neurotomy was performed. In a single patient, an interposition nerve graft was required. Restoration of sensibility was evaluated by the "wrinkle test."

Outcome following spinal accessory to suprascapular (spinoscapular) nerve transfer in infants with brachial plexus birth injuries.

The purpose of this study is to evaluate the value of distal spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) in children with brachial plexus birth injuries in order to better define the application and outcome of this transfer in these infants. Over a 3-year period, 34 infants with brachial plexus injuries underwent transfer of the SAN to the SSN as part of the primary surgical reconstruction. Twenty-five patients (direct repair, n = 20; interposition graft, n = 5) achieved a minimum follow-up of 24 months. Fourteen children underwent plexus reconstruction with SAN-to-SSN transfer at less than 9 months of age, and 11 underwent surgical reconstruction at the age of 9 months or older. Mean age at the time of nerve transfer was 11.6 months (range, 5-30 months). At latest follow-up, active shoulder external rotation was measured in the arm abducted position and confirmed by review of videos. The Gilbert and Miami shoulder classification scores were utilized to report shoulder-specific functional outcomes. The effects of patient age at the time of nerve transfer and the use of interpositional nerve graft were analyzed. Overall mean active external rotation measured 69.6°; mean Gilbert score was 4.1 and the mean Miami score was 7.1, corresponding to overall good shoulder functional outcomes. Similar clinical and shoulder-specific functional outcomes were obtained in patients undergoing early (<9 months of age, n = 14) and late (>9 months of age, n = 11) SAN-to-SSN transfer and primary plexus reconstruction. Nine patients (27%) were lost to follow-up and are not included in the analysis. Optimum results were achieved following direct transfer (n = 20). Results following the use of an interpositional graft (n = 5) were rated satisfactory. No patient required a secondary shoulder procedure during the study period. There were no postoperative complications. Distal SAN-to-SSN (spinoscapular) nerve transfer is a reliable option for shoulder reinnervation in infants with brachial plexus birth injuries. Direct transfer seems to be the optimum method. The age of the patient does not seem to significantly impact on outcome.

Brachial plexus birth palsy: an overview of early treatment considerations.

Since the description by Smellie in 1764, in a French midwifery text, that first suggested an obstetric origin for upper limb birth palsy, great strides have been made in both diagnosis and early and late treatment. This report presents an overview of selected aspects of this complex and extensive subject. Early treatment options are reviewed in the context of the present controversies regarding the natural history and the indications for and timing of microsurgical intervention in infants with brachial plexus birth injuries.

Persistent posterior interosseous nerve palsy associated with a chronic type I Monteggia fracture-dislocation in a child: a case report and review of the literature.

We present a rare case of persistent complete posterior interosseous nerve palsy associated with a chronic type I Monteggia elbow fracture-dislocation consisting of anterior dislocation of the radial head and malunion of the ulna in an 8-year-old child requiring surgical treatment. Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head. This report describes combined treatment of the nerve and skeletal injury for the chronic type I Monteggia injury. The literature is reviewed, and diagnostic challenges with and treatment options for chronic Monteggia fracture-dislocations in children are discussed.